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Safe Cholecystectomy A to Z

  • Dr V K Kapoor
  • Tips for safe cholecystectomy
    • Adequate formal training in minimal invasive surgery, preferably during
    • post graduation or alternatively as an observer but not merely by attending workshops over weekends
    • Proper selection of initial cases - thin built female patient with short history of biliary colics only, no history of acute cholecystitis, thin walled distended gall bladder on ultrasound
    • Proper informed consent (including chances of conversion and higher risk of bile duct injury)
    • Good quality equipment and instruments
    • Proper cleaning and sterilisation of instruments
    • A qualified and trained surgeon as the first assistant
    • Urinary bladder evacuated just before anaesthesia and surgery
    • General anaesthesia
    • Open insertion of first canula
    • 30° telescope
    • All instruments must be introduced, operated and removed under vision
    • Fundus retracted upwards towards right shoulder
    • Gall bladder neck retracted down and out
    • Remember that every patient has his/ her own biliary and vascular anatomy in the Calot’s triangle
    • Cystic lymph node is an important landmark – keep to its right
    • No cautery in Calot’s triangle – it should be used in gall bladder bed only
    • Suction canula is a good instrument for blunt dissection
    • Hug the gall bladder, not the bile duct
    • Clipping of the cystic duct flush with the common bile duct is not required
    • It is safer to leave a few mm of cystic duct than to encroach even 1 mm on the common bile duct
    • Double clips on the retained side of the cystic duct and cystic artery
    • Ligature, Haemoclip, Endoloop and stapler are useful devices to tackle a
    • wide cytic duct
    • Normal sized common bile duct can easily be mistaken for cystic duct
    • Beware of wide cystic duct, long cystic duct, vertical cystic duct – it may
    • be common bile duct
    • Very soft (normal) liver, fatty liver and cirrhotic liver can easily be injured
    • during retraction
    • Fundus first is a useful technique in difficult cases
    • Partial cholecystectomy is an option in case of difficulty
    • Panic should be avoided in case of bleeding
    • Pressure with a gauze or the mobilised gall bladder will control the bleeding or make it controllable
    • Desperate blinds attempts to clip or coagulate a bleeding point in a pool of blood must be avoided
    • Stumps (cystic duct/ cystic artery) should be examined and re-examined for security of clips and any bile leak/ bleed
    • Gall bladder bed should be irrigated and examined for any bleed/ bile leak (from a cholecysto-hepatic duct)
    • Presence of bile should make the surgeon stop and look for the source of bile - gall bladder or bile duct
    • Extraction of gall bladder under vision to make sure that there is no bile/
    • stone spill
    • Spilled bile should be sucked out
    • Spilled stones should be looked for and removed
    • Aponeurosis at 10 mm port sites should be closed
    • Surgeon should not have any ego to complete every cholecystectomy
    • laparoscopically
    • Conversion is a safety valve and an emergency exit
    • Have a low threshold for conversion
    • Conversion is not a failure on the part of the surgeon
    • Cholecystectomy should not be considered a small/ routine operation and should not be taken lightly/ casually
    • Surgeons should avoid the temptation to get their names into books of
    • records
    • Experience is no protection against bile duct injury
    • All gall bladders, even if they look grossly normal, should be sent for
    • histopathology so as not to miss an incidental gall bladder cancer
    • The day after cholecystectomy, the patient should be without pain, sitting up in the bed, having her breakfast and wanting to go home – vitals should be stable/ normal and abdomen soft; if not, observe the patient in the hospital for another day
    • In the era of increasing medical litigation, a safe cholecystectomy is safe
    • not only for the patient but for the surgeon also